migrant women’s experiences of pregnancy, childbirth and

RESEARCH ARTICLE

Migrant women’s experiences of pregnancy,

childbirth and maternity care in European

countries: A systematic review

Frankie FairID1, Liselotte Raben2, Helen WatsonID

1, Victoria Vivilaki3, Maria van den

Muijsenbergh2,4, Hora SoltaniID1*, the ORAMMA team¶

1 Department of Nursing and Midwifery, Sheffield Hallam University, Sheffield, England, United Kingdom,

2 Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, Netherlands,

3 Department of Midwifery, Faculty of Health and Caring Sciences, University of West Attica, Athens,

Greece, 4 Pharos, Centre of Expertise on Health Disparities, Utrecht, Netherlands

¶ Membership of the ORAMMA team is provided in the Acknowledgments.

* [email protected]

Abstract

Background

Across Europe there are increasing numbers of migrant women who are of childbearing

age. Migrant women are at risk of poorer pregnancy outcomes. Models of maternity care

need to be designed to meet the needs of all women in society to ensure equitable access to

services and to address health inequalities.

Objective

To provide up-to-date systematic evidence on migrant women’s experiences of pregnancy,

childbirth and maternity care in their destination European country.

Search strategy

CINAHL, MEDLINE, PubMed, PsycINFO and Scopus were searched for peer-reviewed arti-

cles published between 2007 and 2017.

Selection criteria

Qualitative and mixed-methods studies with a relevant qualitative component were consid-

ered for inclusion if they explored any aspect of migrant women’s experiences of maternity

care in Europe.

Data collection and analysis

Qualitative data were extracted and analysed using thematic synthesis.

Results

The search identified 7472 articles, of which 51 were eligible and included. Studies were

conducted in 14 European countries and focused on women described as migrants,

PLOS ONE | https://doi.org/10.1371/journal.pone.0228378 February 11, 2020 1 / 26

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OPEN ACCESS

Citation: Fair F, Raben L, Watson H, Vivilaki V, van

den Muijsenbergh M, Soltani H, et al. (2020)

Migrant women’s experiences of pregnancy,

childbirth and maternity care in European

countries: A systematic review. PLoS ONE 15(2):

e0228378. https://doi.org/10.1371/journal.

pone.0228378

Editor: Nihaya Daoud, Ben-Gurion University of the

Negev Faculty of Health Sciences, ISRAEL

Received: May 17, 2019

Accepted: January 14, 2020

Published: February 11, 2020

Copyright: © 2020 Fair et al. This is an open access

article distributed under the terms of the Creative

Commons Attribution License, which permits

unrestricted use, distribution, and reproduction in

any medium, provided the original author and

source are credited.

Data Availability Statement: All relevant data are

within the paper and its Supporting Information

files.

Funding: MM,HS & VV - grant received from the

Consumers, Health, Agriculture and Food Executive

Agency (CHAFEA) of the European Commission

Grant Number 738148. http://ec.europa.eu/chafea/

index_en.htm The funders had no role in study

design, data collection and analysis, decision to

publish, or preparation of the manuscript.

http://orcid.org/0000-0001-7613-3393

http://orcid.org/0000-0002-5479-8527

http://orcid.org/0000-0001-9611-6777

https://doi.org/10.1371/journal.pone.0228378

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http://creativecommons.org/licenses/by/4.0/

http://creativecommons.org/licenses/by/4.0/

http://ec.europa.eu/chafea/index_en.htm

http://ec.europa.eu/chafea/index_en.htm

refugees or asylum seekers. Four overarching themes emerged: ‘Finding the way—the

experience of navigating the system in a new place’, ‘We don’t understand each other’, ‘The

way you treat me matters’, and ‘My needs go beyond being pregnant’.

Conclusions

Migrant women need culturally-competent healthcare providers who provide equitable, high

quality and trauma-informed maternity care, undergirded by interdisciplinary and cross-

agency team-working and continuity of care. New models of maternity care are needed

which go beyond clinical care and address migrant women’s unique socioeconomic and

psychosocial needs.

Introduction

International migration continues to grow rapidly [1]. Between 2000 and 2017, the migrant

population increased by 85 million, from 173 to 258 million [1]. In 2017, more than 90 million

international migrants were residing in the World Health Organization (WHO) European

region and more than half of these migrants were women, many of childbearing age [2]. There

are no universally accepted definitions for a migrant at an international level [2] and this het-

erogeneous group includes individuals who vary by length of stay in a country, documentation

and residency status, movement being voluntary or forced, and reasons for migration [2,3].

Health needs and outcomes in this heterogeneous group is a complex topic, as these are influ-

enced by the interaction of the process of migration and exposure to risks and access to the

determinants of health in the country of origin, during transit and in the destination country

[2].

On average the fertility rate in the migration population is higher than the native popula-

tion [4]. Among women living in the United Kingdom, birth data from 2015 show a total fer-

tility rate (the average number of children a woman has in her lifetime) of 2.06 for non-UK

born women versus 1.75 for UK born women [5]. Pregnancy is a period of increased vulnera-

bility for migrant women [6,7]. There is a consistent trend for poorer pregnancy outcomes

amongst migrant women [2] who are at greater risk of maternal and neonatal morbidity and

mortality when compared to native born women [2,8–17]. This is a result of the complex inter-

play of multiple factors including substandard healthcare in the country of origin [2] and

issues around accessing care and the quality of care in the new country [2,14,18]. Moreover,

migration itself can have significant negative consequences for people’s physical and mental

health and their wellbeing due to migration-related social problems, like poor socio-economic

status, discrimination and social exclusion, multiple losses, and the chronic stress caused by

these [19–21]. It is often observed that migrants leaving their country of origin are healthier

than comparable native populations. This phenomenon has been called the “healthy migrant

effect” and is usually explained through the positive self-selection of immigrants and the posi-

tive selection, screening and discrimination applied by host countries [22]. But, although often

healthy when arriving in the country, the health of migrants deteriorates over time, and in gen-

eral, they rate themselves to have poorer health compared to the native population of their

host countries [20].

Across the WHO European region there is consensus and commitment to ensure the avail-

ability, accessibility, affordability and quality of essential health services for migrants in transit

and host environments [23]. Hence European countries have a common responsibility to

Migrant women’s experiences of maternity care


Competing interests: The authors have declared

that no competing interests exist.


tackle inequalities and provide high quality healthcare that meets the needs of childbearing

migrant women. However across European Union (EU) member states, the services provided

for migrants and how they are administered, financed and delivered differs between countries;

with some providing care free of charge, some requiring health insurance and some available

to those making national insurance contributions through a place of work [24].

A previous qualitative evidence synthesis [25] has explored both migrant women’s care

experiences and their perceived care needs for data published prior to June 2010. However, an

updated review was deemed important with the acknowledgement that changing global, politi-

cal and economic climates have led to increased migration into Europe [2,26]. This includes

recent political unrest and conflict in many Middle Eastern and Sub-Saharan countries [26],

the updated rights of free movement of citizens and their families within the European Eco-

nomic Area laid down in a Directive in 2004 [27] and an increased recognition of the need to

integrate the health needs of migrants and refugees into national health strategies [2]. This

review therefore aimed to provide up-to-date systematic evidence on migrant women’s experi-

ences of pregnancy, childbirth and maternity care in their destination country within Europe.

Methods

A systematic search of five databases was undertaken to identify articles pertaining to migrant

women’s experiences of pregnancy and maternity care in their destination country. The fol-

lowing databases were searched; CINAHL, MEDLINE, PUBMED, PSYCHINFO and SCO-

PUS. Databases were searched from 2007 until the final search on 22/05/2017. The point of

commencement was taken as 2007 due to the changing political landscape within the EU at

that point, with the health of migrants being a focus of the EU president in 2007 [28]. The

search strategy comprised of three facets, with terms relating to (i) migrant (ii) maternity and

(iii) experience. The Boolean operators AND and OR were used alongside truncation opera-

tors and phrase-searching, and the search syntax was adapted for each database. The full search

strategy, as applied in MEDLINE (EBSCO interface) is provided in S1 File. In addition to the

electronic database search, the reference lists of eligible studies were examined to identify any

other relevant studies and citation tracking was undertaken.

Study selection and data extraction

Screening of the titles and abstracts against the inclusion and exclusion criteria in Table 1 was

carried out by two researchers independently. This was followed by double-screening the full-

text of potentially relevant sources. Any disagreements concerning eligibility were resolved

through discussion between team members. Study characteristics and all qualitative data that

related to women’s experiences of any aspect of maternity care within the host country were

extracted using a standardised form.

Critical appraisal

Included articles were quality appraised using the qualitative National Institute for Health and

Care Excellence (NICE) critique tool [29] (see S2 File) and 10% were appraised by a second

reviewer to ensure consistency. A low-quality score (-) was assigned if either most criteria

were not met, or it was judged that there were significant flaws in the study design. The article

was classified as moderate quality (+) if most criteria were met and it was identified that there

may be some flaws in the study resulting in a lack of rigor. A high-quality score (++) required

that the majority of the appraisal criteria were met and the study was judged to be trustworthy

and reliable and there was significant evidence of author reflexivity.




Evidence synthesis

A thematic synthesis was undertaken involving 3 separate steps; i) line by line coding adding

new codes to the ’bank’ of codes as required, ii) organising codes into descriptive themes

according to their similarities or differences and using new codes to capture the group of origi-

nal codes, iii) generating analytical themes [30]. Coding was undertaken using NVivo and

Atlas.ti packages. A total of 28% of the articles were double-coded, and development of the

final analytic themes involved discussion with the whole research team to achieve consensus.

Confidence in the findings

The confidence in the findings of this review was assessed independently by two reviewers

using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual)

approach [31,32]. This assesses confidence in the evidence base in four components: (i) meth-

odological limitations which evaluates any methodological concerns in the primary studies

contributing to the review finding, (ii) relevance to the review question evaluates the applica-

bility of primary study data to the context specified in the review question, (iii) coherence

which evaluates the fit between the primary study’s data and the review finding it contributes

to and (iv) adequacy of the data which evaluates the richness and quantity of primary study

data for each review finding [33]. An overall judgement for confidence in each review finding

of ’high’, ’moderate’ or ’low’ was determined based on evaluation of the four components.

Results

A flow diagram of the study selection process can be seen in Fig 1. A total of 7472 citations

were initially identified out of which 51 articles (47 studies) were included.

Description of included studies

The characteristics of the included studies can be seen in Table 2 and the reasons for exclusion

at abstract and full text can be found in S3 File. Of the 47 included studies, 43 exclusively used

qualitative methodology and four adopted a mixed methods approach and reported relevant

qualitative data [34–37]. Individual interviews were exclusively undertaken in 27 of the studies

[8,38–63] and focus groups in five studies [64–68]. Multiple methods of data collection were

Table 1. Inclusion and exclusion criteria.

Inclusion Criteria Exclusion criteria

• Qualitative or mixed-methods studies with a qualitative

component

• Peer reviewed articles

• Exploring any aspect of migrant women’s experiences of

maternity care in the host country

• Study undertaken in Europe

• Published within the last 10 years (from 2007 onwards)

• Studies focussed on women described as migrants,

refugees or asylum seekers, including undocumented

migrants

• Where both first and second-generation migrants were

included within a study, the study was included but where

possible only the views of the first-generation migrant

women were included

• Where studies included both the experiences of migrant

women and health care professionals, only the views of the

migrant women were included

• No language restrictions were put in place

• Internal migrants (eg rural to urban)

• Migration status unclear (eg. studies of ethnic

minorities women with no reference to migration

status)

• Non peer-reviewed articles eg commentaries,

editorials, reports, books, protocols and theses/

dissertations

• Systematic reviews and reviews—however their

references were systematically searched

• Studies focussed solely on women’s experiences of

interventions

https://doi.org/10.1371/journal.pone.0228378.t001





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enfa

cest

ress

ful

situ

atio

ns,

wh

ich

may

dif

fer

acco

rdin

gto

nat

ion

alit

y

and

len

gth

of

stay

inth

eco

un

try

.M

ain

fact

ors

neg

ativ

ely

affe

ctin

gp

reg

nan

cy

wer

est

ress

du

eto

pre

cari

ou

sli

vin

g

con

dit

ion

s,h

eavy

wo

rkd

uri

ng

pre

gn

ancy

,in

adeq

uat

eco

mm

un

icat

ion

wit

hh

ealt

hca

rep

rov

ider

s,an

dfe

elin

gs

of

raci

sman

dd

iscr

imin

atio

nin

soci

ety

On

lyre

sult

sfr

om

mig

ran

tw

om

en

wer

eu

sed

-

Bri

sco

e&

Lav

end

er

(20

09

)[7

0]

Qu

alit

ativ

e.

Lo

ng

itu

din

al

exp

lora

tory

mu

ltip

le

case

stu

dy

UK

4A

fgh

anis

tan

,C

on

go

,

Rw

and

a,S

om

alia

.

19

–3

6y

ears

1–

3T

oex

plo

rean

dsy

nth

esiz

e

fem

ale

asy

lum

seek

ers’

and

refu

gee

s’ex

per

ien

ceo

f

mat

ern

ity

care

In-d

epth

inte

rvie

ws.

Ph

oto

gra

ph

sta

ken

by

the

wo

men

.

Fie

ldn

ote

san

d

ob

serv

atio

n.

Co

nst

ruct

ion

of

them

es

Th

ew

om

enp

erce

ived

‘sel

f’as

are

spo

nse

toso

cial

inte

ract

ion

.A

tti

mes

,‘t

aken

for

gra

nte

d’co

mm

un

icat

ion

inp

ract

ice

crea

ted

ab

arri

erto

un

der

stan

din

gfo

rth

e

wo

men

.S

oci

alp

oli

cyre

late

dto

seek

ing

asy

lum

,d

isp

ersa

l,h

ou

sin

gan

dh

ealt

h

affe

cted

the

lives

and

mat

ern

ity

exp

erie

nce

so

fw

om

en

+

(Con

tinued)




Ta

ble

2.

(Co

nti

nu

ed)

By

rsk

og

etal

(20

16

)[4

0]

An

exp

lora

tive,

qu

alit

ativ

eap

pro

ach

Sw

eden

17

So

mal

ia1

8–

45

yea

rsB

etw

een

0an

d

>7

chil

dre

n

To

exp

lore

ho

wS

om

ali-

bo

rn

wo

men

un

der

stan

dan

dre

late

tov

iole

nce

and

wel

lbei

ng

du

rin

gth

eir

mig

rati

on

tran

siti

on

and

thei

rv

iew

so

n

bei

ng

qu

esti

on

edab

ou

t

vio

len

cein

Sw

edis

han

ten

atal

care

Ind

ivid

ual

sem

i-

stru

ctu

red

inte

rvie

ws

Th

emat

ican

alysi

s.A

bal

anci

ng

act

bet

wee

nk

eep

ing

pri

vat

e

life

pri

vat

ean

dth

en

eww

elfa

resy

stem

was

iden

tifi

ed,

wh

ere

the

mid

wif

e’s

qu

esti

on

sab

ou

tvio

len

cew

ere

met

wit

h

hes

itan

ce.

Th

em

idw

ife

was

,h

ow

ever

,

con

sid

ered

are

sou

rce

for

acce

ssto

sup

po

rtse

rvic

esin

the

new

soci

ety

.A

focu

so

np

rag

mat

icst

rate

gie

sto

mo

ve

on

inli

fe,

rath

erth

and

wel

lin

go

np

ote

nti

al

exp

erie

nce

so

fvio

len

cean

dre

late

d

trau

mas

,w

asp

rom

inen

t.S

oci

al

net

wo

rks,

spir

itu

alfa

ith

and

mo

ther

ho

od

wer

ecr

uci

alfo

rre

gai

nin

gco

her

ence

in

the

afte

rmat

ho

fw

ar.

Dia

log

ue

and

mu

tual

adju

stm

ents

wer

eid

enti

fied

as

stra

teg

ies

use

dto

over

com

ep

ow

er

ten

sio

ns

inin

tim

ate

rela

tio

nsh

ips

un

der

go

ing

tran

siti

on

++

Ch

ou

dh

ry&

Wal

lace

(20

12

)

[41

]

Des

crip

tive

qu

alit

ativ

est

ud

y

UK

20

So

uth

Asi

a.1

1b

orn

in

UK

,9

ou

tsid

eU

K.

No

tre

po

rted

9p

ara

1,9

par

a

2,

2ex

pec

tin

g

firs

tb

aby

To

exp

lore

the

infl

uen

ceo

f

accu

ltu

rati

on

on

bre

astf

eed

ing

pra

ctic

eso

fS

ou

thA

sian

wo

men

.

Sem

i-st

ruct

ure

d

inte

rvie

ws

Th

emat

ican

alysi

s5

them

es-‘M

aaKaa

Dood’(The

mother’s

milk

);T

he

mo

stco

nv

enie

nt

met

ho

dfo

r

me;

Fo

rmu

lafe

edin

gas

aw

ayo

ffu

lfil

lin

g

the

bab

y’s

dem

and

s;B

reas

tis

n’t

alw

ays

bes

t–

wo

men

’sex

per

ien

ceo

f

info

rmat

ion

and

role

con

flic

t;L

earn

ing

by

ob

serv

atio

n–

the

form

ula

feed

ing

cult

ure

On

lyre

sult

sfr

om

mig

ran

tw

om

en

wer

eu

sed

+

Co

uti

nh

oet

al

(20

14

)[4

2]

Qu

alit

ativ

e,

exp

lora

tory

,

des

crip

tiv

est

ud

y

Po

rtu

gal

82

(60

imm

igra

nt

wo

men

and

22

nat

ive

Po

rtu

gu

ese

wo

men

)

Bra

zil,

Uk

rain

e,C

hin

a,

Mo

ldo

va,

Ru

ssia

,

Fra

nce

,S

pan

,In

dia

,

Po

rtu

gal

and

oth

ers

No

tre

po

rted

No

tre

po

rted

To

iden

tify

the

un

met

exp

ecta

tio

ns

of

the

hea

lth

syst

emb

yP

ort

ug

ues

e

and

imm

igra

nt

wo

men

,

du

rin

gp

reg

nan

cy,

chil

db

irth

and

po

stp

artu

m.

Sem

i-st

ruct

ure

d

inte

rvie

ws.

Gu

idel

ines

wer

e

use

d.

Rec

ord

ed.

Co

nte

nt

anal

ysi

sM

ajo

rem

erg

ing

cate

go

ries

of

un

met

exp

ecta

tio

ns

refe

rred

toth

eac

cess

ibil

ity,

hu

man

reso

urc

es,

ince

nti

ves

tom

ater

nit

y

care

,p

hysi

cal

and

envir

on

men

tal

con

dit

ion

s,an

do

rgan

izat

ion

of

the

hea

lth

syst

em.

On

lyre

sult

sfr

om

mig

ran

tw

om

en

wer

eu

sed

-

Deg

ni

etal

(20

14

)[6

7]

Qu

alit

ativ

eF

inla

nd

70

So

mal

iw

om

enfr

om

Ken

ya

(18

),

Mo

gad

ish

u(3

2)

and

Har

gey

sa(2

0)

18

–5

0y

ears

2–

10

chil

dre

nT

oex

plo

reim

mig

ran

tS

om

ali

wo

men

’sex

per

ien

ces

of

rep

rod

uct

ive

and

mat

ern

ity

hea

lth

care

serv

ices

and

thei

r

per

cep

tio

ns

abo

ut

the

serv

ice

pro

vid

ers

Fo

cus

gro

up

s.T

hem

esco

nst

ruct

edP

arti

cip

ants

wer

esa

tisf

ied

wit

hth

eca

re

they

rece

ived

inF

inla

nd

.D

esp

ite

thei

r

sati

sfac

tio

n,

the

hea

lth

care

pro

vid

ers’

soci

alat

titu

des

tow

ard

sth

emw

ere

per

ceiv

edas

un

frie

nd

ly,an

d

com

mu

nic

atio

nas

po

or

++

Dem

pse

y&

Pee

ren

(20

16

)

[43

]

Qu

alit

ativ

e—

gro

un

ded

theo

ry

Irel

and

12

Eas

tern

Eu

rop

e2

0–

40

yea

rsV

arie

d,

nu

mb

ers

no

t

rep

ort

ed.

To

exp

lore

mig

ran

tE

aste

rn

Eu

rop

ean

wo

men

’s

exp

erie

nce

of

pre

gn

ancy

in

Irel

and

Sem

i-st

ruct

ure

d

inte

rvie

ws

Co

nst

ruct

ion

of

them

es

Mig

ran

tw

om

enw

ho

exp

erie

nce

pre

gn

ancy

inth

eir

ho

stco

un

try

face

mu

ltip

le,

mu

lti-

face

ted

chal

len

ges

.

Mig

ran

tE

aste

rnE

uro

pea

nw

om

enm

ay

hav

ep

arti

cula

rst

rug

gle

sw

ith

tran

siti

on

ing

toa

less

med

ical

ised

mat

ern

ity

hea

lth

care

syst

em.

+

Ess

enet

al

(20

11

)[7

1]

Qu

alit

ativ

eU

K1

01

(39

So

mal

i

wo

men

and

62

ob

stet

ric

care

pro

vid

ers)

So

mal

ia1

8–

48

yea

rs(S

om

ali

wo

men

)

1–

10

chil

dre

nT

oex

plo

reth

eat

titu

des

of

So

mal

iw

om

enan

dth

eir

wes

tern

ob

stet

ric

care

pro

vid

ers

tow

ard

sC

aesa

rean

sect

ion

In-d

epth

sem

i-

stru

ctu

red

inte

rvie

ws

and

focu

sg

rou

ps

Fra

mew

ork

of

nat

ura

list

icin

qu

iry

usi

ng

the

emic

/eti

c

mo

del

.

So

mal

iw

om

enex

pre

ssed

fear

and

anx

iety

thro

ug

ho

ut

the

pre

gn

ancy

and

iden

tifi

edst

rate

gie

sto

avo

idca

esar

ean

sect

ion

Avo

idin

go

rre

fusi

ng

caes

area

n

was

bas

edo

na

rati

on

alch

oic

eto

avo

id

dea

than

dco

pin

gw

ith

adv

erse

ou

tco

me

reli

edo

nfa

tali

stic

atti

tud

es

On

lyre

sult

sfr

om

mig

ran

tw

om

en

wer

eu

sed

++

Fel

dm

an(2

01

4)

[44

]

Qu

alit

ativ

eU

K2

0w

om

en1

4d

iffe

ren

tco

un

trie

sN

ot

rep

ort

edN

ot

rep

ort

edT

oin

ves

tig

ate

the

exp

erie

nce

s

of

wo

men

wh

oh

adb

een

dis

per

sed

du

rin

gp

reg

nan

cy

and

of

mid

wiv

esin

vo

lved

in

cari

ng

for

thes

ew

om

en

Ind

ivid

ual

inte

rvie

ws,

face

-to

-

face

or

tele

ph

on

e

No

tsp

ecif

ied

Dis

per

sal

inte

rru

pte

dw

om

en’s

acce

ssto

mat

ern

ity

care

.W

om

enex

per

ien

ced

pra

ctic

alb

arri

ers

toac

cess

ing

care

and

com

mu

nic

atio

np

rob

lem

s.W

om

en

exp

erie

nce

dth

ep

ost

nat

alp

erio

das

emo

tio

nal

and

stre

ssfu

lan

dh

ad

con

cern

sab

ou

tth

eir

livin

gco

nd

itio

ns.

-

Gar

dn

eret

al

(20

14

)[4

5]

Qu

alit

ativ

eU

K6

Nig

eria

and

Gh

ana

22

–2

61

–3

To

exp

lore

the

liv

ed

exp

erie

nce

of

po

stn

atal

dep

ress

ion

inW

est

Afr

ican

mo

ther

sli

vin

gin

the

UK

.

Sem

i-st

ruct

ure

d

inte

rvie

ws

Inte

rpre

tive

Ph

eno

men

olo

gic

al

An

alysi

s

Wes

tA

fric

anm

oth

ers

liv

ing

inth

eU

K

exp

erie

nce

dis

ola

tio

nan

da

lack

of

pra

ctic

al,

emo

tio

nal

and

pro

fess

ion

al

sup

po

rtin

the

po

stn

atal

per

iod

.

+

(Con

tinued)




Ta

ble

2.

(Co

nti

nu

ed)

Gar

nw

eid

ner

etal

(20

13

)[4

6]

Qu

alit

ativ

eN

orw

ay1

7

(5et

hn

ic

No

rweg

ian

and

12

imm

igra

nts

)

Alg

eria

,A

lban

ia,

Pak

ista

n,

Th

aila

nd

,

Tu

rkey

,R

uss

ia,

Sri

Lan

ka,

So

mal

ia.

On

aver

age

28

yea

rs

old

No

tre

po

rted

To

exp

lore

exp

erie

nce

sw

ith

nu

trit

ion

-rel

ated

info

rmat

ion

du

rin

gro

uti

ne

ante

nat

alca

re

amo

ng

wo

men

of

dif

fere

nt

eth

nic

alb

ack

gro

un

ds

Ind

ivid

ual

inte

rvie

ws

Inte

rpre

tati

ve

ph

eno

men

olo

gic

al

anal

ysi

s

Par

tici

pan

tsre

po

rted

that

they

wer

e

pro

vid

edw

ith

litt

len

utr

itio

n-r

elat

ed

info

rmat

ion

.T

he

info

rmat

ion

was

per

ceiv

edas

pre

sen

ted

inver

yg

ener

al

term

san

dfo

cuse

do

nfo

od

safe

ty.

Wei

gh

t

man

agem

ent

and

the

lon

g-t

erm

pre

ven

tio

no

fd

iet-

rela

ted

chro

nic

dis

ease

sh

adh

ard

lyb

een

dis

cuss

ed.

Wo

men

wer

eco

nfu

sed

abo

ut

info

rmat

ion

giv

enb

yth

em

idw

ife

wh

ich

was

inco

ng

ruen

tw

ith

thei

ro

rig

inal

foo

d

cult

ure

.T

he

par

tici

pan

tsw

ere

acti

vel

y

seek

ing

for

nu

trit

ion

-rel

ated

info

rmat

ion

On

lyre

sult

sfr

om

mig

ran

tw

om

en

wer

eu

sed

+

Gar

nw

eid

ner

etal

(20

17

)[4

7]

An

exp

lora

tiv

e

qu

alit

ativ

eap

pro

ach

No

rway

8 (5im

mig

ran

ts

and

3et

hn

ic

No

rweg

ian

Iraq

,T

urk

ey,

Pak

ista

n,

Po

lan

d,

Sp

ain

and

No

rway

No

tre

po

rted

1–

3ch

ild

ren

To

inves

tig

ate

pre

gn

ant

wo

men

’sex

per

ien

ces

of

do

mes

tic

vio

len

cean

dh

ow

this

isad

dre

ssed

inan

ten

atal

care

Ind

ivid

ual

sem

i-

stru

ctu

red

inte

rvie

ws

Th

emat

ican

alysi

s

acco

rdin

gto

Even

tho

ug

hn

on

eo

fth

ep

arti

cip

ants

wer

eas

ked

abo

ut

do

mes

tic

vio

len

cein

ante

nat

alca

re,th

eyo

ffer

edd

iffe

ren

t

sug

ges

tio

ns

on

ho

wan

dw

hen

mid

wiv

es

sho

uld

talk

abo

ut

it.

On

lyre

sult

sfr

om

mig

ran

tw

om

en

wer

eu

sed

-

Gau

dio

n&

All

ote

y(2

00

9)

[72

]

Qu

alit

ativ

eU

K4

3A

fgh

anis

tan

,C

hin

a,

Eri

trea

,E

thio

pia

,Ir

aq,

Iran

,S

riL

ank

a,

So

mal

ia,

Cen

tral

and

Wes

tA

fric

a,U

gan

da,

Zim

bab

we

and

Ru

ssia

Man

yw

ere

teen

ager

s

wh

oen

tere

dU

Kas

un

acco

mp

anie

d

asy

lum

seek

ing

chil

dre

n(o

ther

wis

e

NR

)

No

tre

po

rted

To

des

crib

ere

fug

eean

d

asy

lum

seek

ing

wo

men

’s

exp

erie

nce

so

fp

reg

nan

cy,

chil

db

irth

and

mat

ern

ity

serv

ices

Inte

rvie

ws

and

focu

sg

rou

ps

Th

emat

ican

aly

sis.

Wo

men

rep

ort

edo

ver

stre

tch

edse

rvic

es,

lan

gu

age

and

com

mu

nic

atio

np

rob

lem

s,

issu

esar

ou

nd

acce

ssan

den

gag

emen

t,

and

the

imp

ort

ance

of

cult

ura

lis

sues

.

Tee

nag

ers

wer

e

also

incl

ud

ed

-

Git

sels

-van

der

Wal

etal

(20

15

)

[48

]

Qu

alit

ativ

eN

eth

erla

nd

s1

2M

oro

cco

20

–3

6y

ears

0–

3ch

ild

ren

To

exp

lore

the

pre

fere

nce

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[51

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f

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(Con

tinued)




Ta

ble

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nu

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ker

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11

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[74

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8]

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3–

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used in fourteen studies [34–36,69–79] including eight which conducted both interviews and

focus groups with different groups of women [69,71–75,77,79]. One study used a question-

naire which included relevant qualitative data [37]. Studies were undertaken in 14 European

countries, ranged in size from four [70] to 193 [37] participants and included a total of 1330

migrant women, although one study did not specify the number of participants and could not

be included in this number [34]. The majority of studies (n = 34) were published from 2012

onwards. A total of seven studies were rated as high quality [35,40,60,64,67,71,74], 22 were of

Fig 1. Flowchart of study selection.

https://doi.org/10.1371/journal.pone.0228378.g001



https://doi.org/10.1371/journal.pone.0228378.g001


moderate quality [38,39,41,43,45,46,48,53,55–57,61–63,65,70,73,75–79] and 18 of low quality

[8,34,36,37,42,44,47,49–52,54,58,59,66,68,69,72].

Data synthesis

Four overarching analytic themes emerged from the literature.

Finding the way—navigating the system in a new place. Weighing it up. Before accessing

maternity care women considered the value [35,51,52,60,81,82], and necessity [65] of care.

They also weighed up the financial costs of accessing care [37,49,61], and the consequences of

accessing care, particularly when they had a lack of trust in healthcare providers (HCPs)

[39,75], previous poor experiences with HCPs [38], or were fearful that their visibility in

maternity services could result in deportation [35,36,66,82].

“I had my first daughter when I was illegal, it has been a terrible experience even though mysister helped me, I was always fearing that someone would knock at the door and would sendus back to Portugal. . . Even when I had contractions I was afraid to go to the hospital fearingto be sent back to Portugal." (Bollini et al 2007, pp.82) [66]

Finding the way in and through the system. For some migrant women who wanted to access

care, there were difficulties in finding the way into the system. The system was unfamiliar and

different to that of their country of origin and the women were often unaware of their rights

and entitlement to care [34,36,42,53,61,65,72,78,82,83]. There was a lack of information about

the services that were available and if the services were free [36,53,61,82]. Some women faced

difficulties in being accepted for registration for primary healthcare services [36,53,82], were

refused entry to healthcare facilities [75], and struggled to provide the required documentation

or insurance that were prerequisites for care [66,80]. Having friends and relatives who had

already settled in the new country and could speak the local language helped migrant women

find the way into the system, along with NGOs who provided information about entitlement

and available services [36,51]. Women being held in detention centres were isolated from

these sources of help and reported that the way into the system was blocked by detention cen-

tre staff who refused or delayed their access to care [35,53].

"The Home Office put me in detention centre so I could not attend my appointments. Therewere no maternity services there for me for the 2 months I was there. I was offered appoint-ments but they were cancelled at short notice without anyone telling me why." (Phillimore

2015, pp.576) [35]

Costs related to transportation and payment for care were identified as factors influencing

ongoing access to care [34,44,53,61,83]. Those who received free care identified that this

enabled them to access care, which was often in contrast to the situation in their country of ori-

gin [37,49,67,81]. Flexibility in the system in relation to the timing and location of appoint-

ments influenced access [61,65,70]. Inflexibility in the system, such as the rigid use of

telephone booking systems for appointments were an ongoing barrier that women faced when

trying to navigate the system in a new language [34,75,82].

“I get so nervous to communicate through the telephone, is so difficult . . . instead I go there toget an appointment but they tell me I have to phone . . .Why?” (Robertson 2015, pp.62) [75]




We don’t understand each other. Women highlighted that information, advice and the

opportunity to discuss their health and the health of their unborn child with a HCP was

extremely important to them [63,74,78]. However, they identified a range of issues related to

communication and understanding which are discussed in the sub-themes; Overcoming lan-

guage barriers, Unmet information needs and Different expectations of care.

Overcoming language barriers. Women faced significant language barriers in the new coun-

try and felt that their language difficulties made them problem patients [69], that impacted on

their relationship with their HCPs [37,53,66,78]. Even when women could proficiently manage

everyday situations, they still often lacked the vocabulary to cope with medical terminology

[53,58,70,75].

"I asked them, “[Can] we cancel the meeting until we get an interpreter. . . I didn’t understandyou and you didn’t understand me.” She said, “No, it’s OK, we can go on—you understandEnglish.”’ (Lephard & Haith-Cooper 2016, pp. 134) [53]

Failure to use professional interpreters was a barrier to receiving satisfactory care

[38,44,58,60,69,83], hindered accurate information sharing and led to frequent misinterpreta-

tion [52,70,81] and a lack of understanding of procedures women were asked to give consent

for [35,52,60].

“They [midwives] communicated by sign language and I was never sure I had understoodproperly.” (Briscoe & Lavender 2009, pp.20) [707]

However, the use of professional interpreters was met with caution when discussing inti-

mate or difficult matters [47,69,74,82] or when women had come from areas of persecution

leaving them suspicious of everyone [75]. When women’s partners were asked to interpret

during care encounters some women felt vulnerable [35,82,83] and embarrassed [51,74] and

felt that their partners were reluctant to reveal their own poor understanding [52,70,74].

“If I could have someone who is not my husband it could make a big difference becausethroughout my pregnancy I did not say anything about my needs or problems. My husbandwas saying everything.” (Phillimore 2015 pp.576) [35]

Unmet information needs. Women identified a lack of information around pregnancy,

childbirth or the postpartum period, and a lack of information that was available in an accessi-

ble language or format [8,35,37,46–50,52,58,64,66,70–72,75–79,81–83]. Professional advice

often conflicted with cultural and family advice [41,46,49,54,63,77–79] and this left women

feeling insecure about which actions to take [46,63,77].

"I did not give water, and I was criticized by my family and relatives. They told me: He is ahuman being, he gets thirsty and that milk does not quench thirst. . . while the health clinicsaid: no, he does not need water" (Wandal et al 2016, pp.4) [77]

Women also identified that their care and safety were adversely affected when they did not

disclose important information to HCPs, as did not want to be a nuisance or failed to under-

stand the importance of their health history or potential seriousness of their current or previ-

ous symptoms [52,76].




"I thought: it is a holiday, I do not want to be a problem for someone. I will try to go Mondayor Tuesday after the holidays. But I think now: why did I wait ? Why didn't I phone immedi-ately ?" (Jonkers et al 2011, pp.149) [52]

Different expectations of care. Some women reported being fearful of being treated poorly in

the new country when their expectation of maternity care was based on poor experiences in

their country of origin [60,61].

"I was so scared of them (the midwives). . . I thought they would beat me. . .if I scream or if Icry. So in labour I don't speak, so that I don't upset them." (Tobin et al 2014, pp.836) [60]

Procedures which were familiar to practitioners were not always familiar to women coming

from other care systems [8,70], and this caused women to feel fearful [60,82] and to lack trust

in the information provided by HCPs [39].

“They were putting all those funny cords around me which were so tight, so irritating, I didn'tknow what those were, I never had seen them before. It's like going to another planet and youare seeing all these things which are happening to you and you can't ask anything.” (Tobin

et al 2014, pp.836) [60]

Women’s cultural backgrounds influenced some of their preferences [39,56,60,71] and

beliefs about procedures [49,55,67,70,71,81] and the way they wanted to discuss these [56,74].

Experiences in their country of origin influenced their expectation of the need for medical sur-

veillance and interventions during pregnancy and childbirth [8,42,43,63,80,81].

"According to our religion, we Somali women, we don’t think that giving birth by caesareansection is a good thing and that a woman should give birth by vagina and not by opening herstomach to take the baby out. Somali women’s general belief is that caesarean birth is not areal way of a woman to give birth. And how many times doctors will cut her stomach if shehas to deliver many times in her life?" (Degni et al 2014, pp.357) [67]

“I found it extremely friendly but very low in real medicine? It’s all midwife based, no exams,which is very strange for me”. (Dempsey & Peeren 2016, pp.377) [43]

The way you treat me matters. Impact of poor care. The HCPs attitude was an important

factor in how migrant women perceived the quality of care. Some women found HCPs to be

unfriendly [67,74] and disrespectful [63,81], failing to respond to their concerns in a caring

matter, ignoring them [74,75] and not taking their complaints seriously [49,52,66,74,75]. This

made women doubt their own capabilities [75]. Unsatisfactory interactions with HCPs often

led to a lack of connection and poor relationships with HCPs which resulted in women feeling

isolated and fearful of being mistreated [60].

"Really they should have asked in a friendly way if we needed help. . .it was a very unpleasantexperience, I felt like an idiot, as totally incompetent.” (Robertson, 2015, pp.63) [75]

When encountering the healthcare system, migrant women expressed a sense of being seen

and treated differently [37,50,53,75,76]. Many women felt that their customs and culture were

not understood by those caring for them [35,37,45,54,55,64,67,76,78,83]. Prejudice and stereo-

typing by HCPs [8,35,37,57,58,66,75,77,78] led to assumptions based on women’s perceived

cultural backgrounds and left them feeling that their needs were overlooked [35,52,53]. In




contrast some HCPs were noted to overly focus on cultural and psychosocial factors when

assessing patient’s symptoms, and therefore overlook potentially serious medical conditions

[50,67].

“I think that people that work in the health care settings . . . the doctors, the nurses, the mid-wives and even cleaners need education in different cultures. They need to understand thatpatients from different cultures and race are not inferiors and not . . .monsters.” (Degni et al

2014, pp.360) [67]

Migrant women highlighted several other factors which resulted in inadequate and ineffec-

tive care including; long waiting times for appointments [61,80], the perceived busyness of

HCPs which prevented women sharing their anxieties and concerns [70,81,82], inadequate

knowledge of legislation by administrative staff [80], not being involved in decision-making

[80], and limited access to specialist care [80].

Importance of good care. Women stressed the importance of good quality care and reported

several examples from their experiences. They valued HCPs who were encouraging and reas-

suring [50,60,77], supportive [43,46,50,70,75] good listeners [50,71] and good information-

providers [50,57,74]. Moreover, they wanted to be cared for by HCPs who had a respectful atti-

tude [43,48,62,74], made them feel emotionally safe [43] and would take their concerns seri-

ously [75]. Women also appreciated HCPs who demonstrated cultural sensitivity, although

this did not necessarily require an in-depth knowledge of individual customs and traditions

[48,78].

‘You know when I talk about myself I feel good about it because I know there’s someone who’slistening and understanding which makes me feel better.’ (Briscoe & Lavender 2009, pp.20)

[70]

Good care encompassed a trusting relationship between women and HCPs, which empow-

ered women to feel confident and prepared for childbirth [63,75,78], even overcoming a lack

of social networks or support [75].

“When one feels well-treated and cared for, one never forgets it. . .especially when you feellonely and vulnerable with a lot of need of support. . .it is worth so much.” (Robertson

2015, pp.63) [75]

Continuity of care was seen as an important factor in establishing these trusting relation-

ships [51,58,63,75,78,81]. Individualised care, with friendly, unhurried HCPs encouraged

women to attend for maternity care and positively influenced their sense of well-being

[37,74,81]. Fragmented care given by different midwives negatively influenced the effective-

ness of care and the women’s confidence to attend appointments [82].

"For example, when I was struck by panic again, I went to the delivery ward, and there wasthe same midwife, and (she) immediately knew me. Yes, she remembered the name and that itwas the first pregnancy, it was nice.. .. It felt like she was a relative." (Wikberg et al

2012, pp.644) [78]

Women also identified that good care required facilities that were hygienic [37,74] and pro-

moted privacy [81] and informed choice [74,78].




My needs go beyond being pregnant. Many migrant women presented to their HCPs

and to the researchers in the primary studies with needs that were outside the ordinary remit

of maternity healthcare provision and beyond the issue of their pregnancy. Preoccupation

with these other needs impacted on their time and ability to focus on the pregnancy [35,36,62].

"I was so busy to survive, to find food, and shelter. I simply did not think of antenatal checksat all." (Schoevers et al 2010, pp.260) [36]

Financial difficulties and poor living conditions. Financial pressures were identified by many

migrant women which led to difficulties covering basic living costs [35,82,83], transport to

appointments [35,53,72,82,83] and costs of essential care [51]. This was exacerbated by not

being allowed to work in the host country [35,66,70,82] or difficultly securing a job

[49,63,74,75]. Although some women encountered actual or feared employment insecurity

[35,61,65,66,82] and exploitation [66], others appreciated the protection of national employ-

ment laws [81].

“worst aspect I think during pregnancy he want to dismiss me [. . .] but could not, could notbecause I had my rights, [. . .] but he fired me soon after the birth of my daughter” (Topa et al

2017 pp.115) [61]

Concerns over living conditions were also common [44,52,53,62,66,70,73,83] and included;

living in temporary [70] or shared accommodation [44,53], poor housing conditions [44,70]

and the impact of dispersal [35,44,53,70,73,82], whereby women were moved by migration

authorities to new, unknown areas within the host country. This increased women’s feelings of

stress [44] and powerlessness [70].

“They give me a [hotel] room. . . [It was] very small, it was smelling of cigarettes. The duvetwas very dirty. The bed. . . the walls. . . everything was very dirty.” (Lephard & Haith-Cooper

2016, pp.132) [53]

“They were saying they’re taking me to Birmingham. I had no one in Birmingham. I don’tknow anyone at all in Birmingham. I was like Oh God, where are they taking me?” (Briscoe &

Lavendar 2009, pp.21) [70]

The burden of traumatic experiences. Many childbearing women had experienced trauma or

persecution prior to or during migration [45,52,60–63,75], and the resulting stress often

became evident as pain and illness in their body [75]. These experiences left women with a lost

or negative sense of identity [45,58,70] and being unwilling to trust their interpretations of

their bodily symptoms [75].

‘‘People were killed; I survived, because they thought I was dead, you can see the scars on myface, where the bullets entered my face . . . They did what they wanted with us, beating us,having rape parties" (Treisman et al 2014, pp.150) [62]

Social support and relationship issues. Childbearing women who had family present in their

destination country appreciated their assistance with domestic tasks [49,68,79] and their guid-

ance [49,74,79,81], and support [56,59,71]. However, many migrant childbearing women

lacked this social support and this left them feeling lonely [45,51,53,60,63,64,73,78,83], isolated

[35,44,45,47,49,58,60,70,74,78,79], hopeless [51] and deeply distressed [37,60,70,74]. Women

were particularly aware of the lack of support from their own mothers [45,53,60,74,78,81] and




highlighted that being able to contact family members was important [63]. Without family

support women were worried about having no one to ask for advice [74,78,81], found raising

children more difficult [74,77,81] and felt that the changes in societal roles [61,75] and lack of

other social support [40] caused tension in the relationship with their partners [75].

“This was my first baby, I was afraid and also I don’t have family here. . . and was crying allthe time and very lonely.” (Babatunde & Moreno-Leguizamon 2012, pp.5) [64]

Women who experienced domestic violence were restricted from talking about this as it

was often not acceptable within their culture [47] and they were not always aware that violence

was forbidden in the destination country [47]. Where the woman experiencing abuse was also

dependent upon the partners’ family for communication with HCPs it left her unable to talk

openly about her circumstances or to report pregnancy problems [35]. Although the midwife

was seen as a resource to signpost to domestic violence support services by some [40], others

were unsure if a midwife could help them [40,47].

“. . .I don't believe a Somali woman would go and tell her (the midwife) if she is having prob-lems or anything like that. . .if it has gone far enough that a woman has decided to report theman, then she knows she can call the police, or that she can get help from friends instead”.(Byrskog et al 2016, pp. 12) [40]

CERQual assessment

The summary scores from the CERQual assessment of confidence in the findings can be seen

in Table 3 and full details are shown in S4 File. A total of 16 findings were assessed, with twelve

scoring high confidence and three scoring moderate confidence and one scoring low

confidence.

Discussion

Main findings

Migrant women’s struggles with communication and language barriers are recurrent themes

within this and previous reviews. Migrant women report a poor understanding of medical ter-

minology [25] and yet there is inadequate use of interpreters within the healthcare system

[25,84]. Poor communication and the provision of insufficient information impact on wom-

en’s ability to choose appropriate care options and provide informed consent [25,84–87]. An

inability to converse in the local language also means women find it difficult to establish a rela-

tionship with their care provider and this impacts upon women accessing care [25,84,88,89].

HCPs can help women to overcome language barriers by providing appropriate information,

engaging professional interpreters more frequently and ensuring they give women the oppor-

tunity to ask the questions that they have [90–99].

In line with other studies [25,85–87,89,100,101], a lack of understanding between migrants

and HCPs in terms of their traditional customs and their expectations of maternity care was

found to impact upon their access of services. The issues clearly point to a need for HCPs to

receive education and training in culturally competent care to better identify women’s expecta-

tions of care and how to understand and appropriately respond to women’s needs related to

their cultural background, to ensure effective maternity care and reduce barriers to accessing

care [22].

Women’s fear of deportation impacting upon use of services identified within this review is

in line with previous literature [88] as is lack of awareness of entitlements to maternity care




[86]. The United Nations, to which all European countries belong, has developed the Conven-

tion on the Elimination of all Forms of Discrimination Against Women [102] which states that

all maternity services, including routine antenatal treatment, must be treated as being immedi-

ately necessary; ‘No woman must ever be denied, or have delayed, maternity services due tocharging issues’ (Department of Health and Social Care (2018) p. 67) [103]. Healthcare provid-

ers need to ensure the provision of adequate support and timely advice for migrant mothers

on their entitlements to care to allay fears and improve access to care, with the ultimate aim of

reducing pregnancy complications.

While the healthy migrant phenomenon may mean that some migrants are healthier than

the native population [22]; a theme which emerged particularly strongly within this review is

that to meet the unique needs of many migrant women there is a necessity for care which goes

beyond traditional models. Other academic studies and reports have highlighted migrant

women’s unstable or inappropriate living conditions, their financial struggles [25,89,104,105]

and the enormous burden of loneliness and the lack of a family network around them

[25,85,100,104–106]. As the wider determinants of health are well recognised [107], including

intimate partner violence [108], low health literacy [109–111], limited social support [112];

Table 3. CERQual summary scores.

Analytic theme Review finding CERQual assessment of

confidence in the evidence

Finding the way—Navigating

the system in a new place

Migrant women weigh up the value of maternity

care and the costs and consequences of accessing

care.

HIGH

Some migrant women are unaware of their rights

and entitlements to maternity care.

HIGH

Migrant women face difficulties in finding the way

into the maternity care system.

HIGH

Ongoing access to maternity care is influenced by

financial factors

HIGH

Ongoing access to maternity care is influenced by

flexibility in the system

MODERATE

We don’t understand each

other

Migrant women face language barriers when

accessing maternity care

HIGH

Migrant women have unmet perinatal information

needs

MODERATE

Migrant women have different expectations of

maternity care

HIGH

The way you treat me matters Migrant women experience prejudice and

stereotyping from HCPs

HIGH

Maternity care is culturally insensitive to migrant

women’s needs

HIGH

Migrant women value continuity of care MODERATE

Migrant women value trusting relationships with

HCPs who demonstrate good professional

behaviours

HIGH

Migrant women value high quality maternity

facilities

LOW

My needs go beyond being

pregnant

Migrant women face financial difficulties and poor

living conditions

HIGH

Migrant women carry the burden of previous

traumatic experiences

HIGH

Migrant women have needs related to social

support and relationship issues

HIGH






addressing social and mental wellbeing alongside physical wellbeing is seen as important for

the overall health of mothers and their infants [113]. Addressing the wider determinants of

health which impact on migrant women requires closer cross-agency working with effective

collaboration between healthcare, social care, the voluntary sector and communities [2]. This

current review also highlighted that many migrant women have experienced trauma prior to

and during migration, which is widely recognised to impact on mental health and wellbeing in

the destination country [114]. Maternity services should develop trauma-informed care [115]

to promote a culture of safety and avoid re-traumatisation through staff training and reviewing

policies and procedures through a trauma lens and developing pathways of support to meet

the needs of these vulnerable women [115].

Some migrant women described exemplary care, receiving treatment that was empathetic,

caring, culturally sensitive and compassionate. However other migrants reported discrimina-

tion prevalent in the HCPs that they encountered. Care is seen to be impacted where women

do not feel well treated or where they feel discriminated against [84,85], while unrushed, kind,

empathetic HCPs are appreciated [25,84,85]. Our findings suggest that continuity of care

increases migrant women’s satisfaction with maternity care. This is in line with the Cochrane

review into continuity of midwife care models which has found increased satisfaction reported

by women receiving continuity by a known midwife, as well as reduced rates of preterm birth

and perinatal death [116]. To address the social determinants of health and avoid discriminat-

ing against migrant women, it calls for person-centred, high-quality, continuity of care that

incorporates aspects of cultural competency and trauma aware care. The evidence within this

review, alongside other evidence, led to the development of the ORAMMA integrated perina-

tal care model [117]. This model has been feasibility tested and will be reported in further arti-

cles currently under development. Other known integrated healthcare models include

Community Orientated Primary Care [118,119], as well as the integrated approach developed

within the European Refugees-Human Movement and Advisory Network (EUR-Human)

project [120].

Strengths and limitations

This review provides up-to-date, systematic evidence located using a comprehensive search

undertaken by a multidisciplinary team. Assessing confidence in the evidence using the

CERQual approach is a further strength of this review. The review is strengthened by the inclu-

sion of a large number of eligible studies set in 14 different European countries which included

migrant women from a wide range of countries of origin. However, some papers did not pro-

vide a clear or consistent definition for the term ’migrant’ or provide details about how

recently the women within their study had arrived in the host country, the specific country of

origin or the reason for migration. Hence, some issues that may be more pertinent to particu-

lar migrants may not be visible within this synthesis. This review focussed exclusively on

migrant women’s experiences of maternity care within European host countries. It is recog-

nised that many experiences may overlap with migrant experiences across other world regions

for example social isolation, language and cultural barriers. However, to ensure local applica-

bility further in-depth investigation would be required on country or community specific fac-

tors influencing migrant experiences.

Conclusion

There are several implications for practice and research from this review.




• It is important that migrant women feel understood. Professional interpreters should be pro-

vided at each appointment/care encounter to enable HCPs to listen to women and build a

friendly, trusting relationship with women.

• HCPs should avoid stereotyping and respect and accommodate traditional or cultural prac-

tices that are relevant in the perinatal period.

• Migrant women’s needs go beyond their pregnancy and include psychosocial-emotional and

economic challenges. To address these needs cross-agency working is needed alongside cul-

turally competent and trauma-informed models of maternity care that incorporates

continuity.

• Future research should focus on providing robust evidence on clinical perinatal outcomes

for migrant mothers and explore the needs of different migrant populations to facilitate

development of tailored interventions.

Supporting information

S1 File. Search strategy.

(DOCX)

S2 File. Critique tool.

(DOCX)

S3 File. Excluded studies.

(DOCX)

S4 File. Full CERQual assessment scoring table.

(DOCX)

S1 PRISMA Checklist.

(DOC)

Acknowledgments

ORAMMA team members are:

M Papadakaki Department of Social Work, School of Health Sciences, Hellenic Mediterra-

nean University, Heraklion, Greece; M Jokinen Practice and Standards Professional Advisor,

The Royal College of Midwives, London, UK; President of European Midwives Association

(EMA) and Vice Chair European Forum for National Nurses and Midwives Associations

(EFNNMA); E Shaw Centre for the History of Science, Technology and Medicine at the Uni-

versity of Manchester, Manchester, UK; E Sioti Department of Midwifery, Faculty of Health

and Caring Sciences, University of West Attica, Athens, Greece; T. Mastrogiannakis CMT

Prooptiki, Athens, Greece; A Markatou CMT Prooptiki, Athens, Greece; D Aarendonk Euro-

pean Forum for Primary Care, Utrecht, Netherlands; and D Castro Sandoval European Forum

for Primary Care, Utrecht, Netherlands.

Co-ordinator for the ORAMMA consortium is Victoria Vivilaki, email: v_vivilaki@yahoo.

co.uk

The content of this article represents the views of the authors only and is their sole responsi-

bility, it cannot be considered to reflect the views of the European Commission and/or the

Consumers, Health, Agriculture and Food Executive Agency or any other body of the Euro-

pean Union. The European Commission and the Agency do not accept any responsibility for

use that may be made of the information it contains.



http://www.plosone.org/article/fetchSingleRepresentation.action?uri=info:doi/10.1371/journal.pone.0228378.s001






Author Contributions

Conceptualization: Victoria Vivilaki, Hora Soltani.

Formal analysis: Frankie Fair, Liselotte Raben, Helen Watson, Maria van den Muijsenbergh,

Hora Soltani.

Funding acquisition: Victoria Vivilaki.

Investigation: Frankie Fair, Liselotte Raben, Helen Watson, Maria van den Muijsenbergh,

Hora Soltani.

Methodology: Frankie Fair, Maria van den Muijsenbergh, Hora Soltani.

Writing – original draft: Frankie Fair, Liselotte Raben, Helen Watson.

Writing – review & editing: Frankie Fair, Liselotte Raben, Helen Watson, Maria van den

Muijsenbergh, Hora Soltani.

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